No airplane should take off without an EpiPen onboard

Jul 25, 2023

I was in seat 20C on a flight home in March when I felt my throat closing. Minutes earlier, hives had appeared on my face and chest. As a physician, I knew exactly what these symptoms meant: anaphylaxis, a severe allergic reaction so precipitously fatal that putting a breathing tube down someone’s throat is sometimes necessary.

What I needed was an epinephrine auto-injector, also known as an EpiPen, but neither the airplane emergency medical kit nor any other passenger had one. The kit did have a glass vial of epinephrine, but without someone to safely administer it with a syringe it was useless. My family helplessly watched me struggle to breathe. We were still 30 minutes from landing.

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I’m alive today because another physician happened to be on my flight and knew how to safely give epinephrine from the glass vial stocked in the kit. But others may not be so lucky. The Federal Aviation Administration must require airlines to include epinephrine auto-injectors in their emergency medical kits to save passengers’ lives.

An estimated 32 million Americans have food allergies, and each year 200,000 of them require emergency medical care. Adults can develop new allergies, as I did, though my trigger still remains unknown.

Anaphylaxis, a severe allergic reaction, is a life-threatening medical emergency and has to be treated with epinephrine as soon as possible. The glass vial of epinephrine planes carry is hard to use, and administering it safely involves multiple time-consuming steps that require medical knowledge.

But anyone can use epinephrine auto-injectors, which take less than 10 seconds to give and commonly come with instructions, making them a safer and more practical treatment for in-flight emergencies.

I was lucky there was epinephrine in any form onboard. The FAA allows planes to fly without a complete emergency medical kit onboard due to exemptions they’ve granted to airlines since 2016. A complete emergency medical kit, defined and last updated by the FAA almost 20 years ago, contains a minimum of 25 instruments and multiple life-saving medications including epinephrine (but only in vial form), atropine, dextrose, and lidocaine — all requiring syringe training to administer.

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But airline lobbying groups or individual airlines can apply for an exemption “for use during temporary supply shortages.” Those “temporary” exemptions last for four years and can be renewed. It’s true that epinephrine auto-injectors were in shortage beginning in 2018. The Food and Drug Administration tracks drug shortages online and a search for epinephrine auto-injectors shows the status as resolved which, by its own definition, indicates “a situation in which the market demand is covered and no supply issues are anticipated by the manufacturers.”

As a physician, it is concerning that in the letter granting the 2016 exemption, epinephrine is described as “a medication mainly used for cardiac resuscitation,” with no mention of anaphylaxis or allergies in the 13-page document. Perhaps an accurate and complete understanding of the emergency uses of epinephrine should be considered before asserting that not including it in any form onboard “would not adversely affect safety.” I know from professional and personal experience this is an untrue and dangerous policy.

The true motivation behind airlines pursuing these exemptions is likely cost, as a glass vial of epinephrine, like the one of my flight, retails for about $5, while an epinephrine auto-injector can cost up to a couple of hundred dollars.

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Crowdsourcing for life-saving medications like epinephrine auto-injectors and hoping someone onboard will have medical training is not a safe or acceptable emergency preparedness strategy. The FAA must update its emergency medical kit requirements to include epinephrine auto-injectors. Too many lives are at stake in waiting for the current exemption to expire next year or, worse, risking it being renewed for another four years.

The FAA’s authorization expires in September. The Federal Aviation Administration Reauthorization Act of 2023 offers an opportunity to update the requirements for emergency medical kits.

Until the FAA requires epinephrine auto-injectors to be included in commercial airlines’ emergency medical kits, many people take a grave risk of losing much more than our luggage each time we fly.

Lindsey Ulin is an internal medicine resident physician at Brigham and Women’s Hospital. A version of this essay first appeared in STAT News, a publication owned by Boston Globe Media Partners that reports on health, medicine, and scientific discovery.